When Is Medicare Secondary?

In order to help clarify things, the following are examples of when Medicare is the secondary payer

Patient is 65 or older and has Group Health Coverage through employment
Whether the recipient’s Group Health coverage comes from their employer or their spouse’s, the Group Health is considered to be the primary payer.

Patient is under 65, disabled, and has Group Health Coverage
If the Group Health Coverage is a plan with more than 100 employees, then the private insurer is to pay first.

End-Stage Renal Disease (ESRD) and the patient has Group Health Coverage
The first 30 months after the diagnosis, it is the Group Health plan which covers costs. After 30 months, Medicare will take over.

End-Stage Renal Disease and the patient is covered by COBRA
COBRA will be responsible for costs in the first 30 months of kidney failure and, again, Medicare will take over after that.

Patient is covered by Worker’s Compensation, No-Fault or Liability Insurance

Medicare is the secondary payer when the client is covered by an accident on the job and is receiving worker’s compensation. It is also the second payer if the person is receiving coverage from no-fault or liability insurance.

Other Situations

There are a few cases when Medicare will pay even if they are the secondary payer. If a person is covered by Worker’s Compensation, Liability or No-Fault insurance and has medical costs which either are not associated with the injury or are not covered by the primary insurer. If a Group Health plan specifically denies payment for a procedure or item which is not covered, then Medicare may step in and make the payment instead.